Failure to Ensure Communication and Documentation for Dialysis Services
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the hemodialysis center and did not consistently complete pre- and post-dialysis assessments for two residents requiring hemodialysis services. For one resident with end stage kidney disease and diabetes, the care plan required monitoring for complications and regular dialysis attendance, but documentation revealed missing post-dialysis assessments on multiple dates and a lack of after-visit summaries from the dialysis center. Staff interviews confirmed that communication packets were inconsistently managed, and necessary documentation from the dialysis center was often not received or completed. For another resident with similar diagnoses, the care plan also required monitoring and regular dialysis, but there were no completed pre- or post-dialysis assessments for an extended period, and specific assessments were missing on additional dates. Progress notes indicated that the resident was sent to the hospital from dialysis without timely communication. Staff acknowledged gaps in documentation and communication with the dialysis center, including missing run sheets that contained critical clinical information. The facility did not have contracts with the dialysis centers providing care to these residents, and no additional documentation was provided regarding their dialysis care.